Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Contro! and Prevention
Illness Compensation Program Act National Institute for Occupational Safety and Heaith
OMB Number: 0920-0639 Expires: 07/31/2016

Special Exposure Cohort Petition — Form B

Basis for Proposing that Records and Information are Inadequate fo:
Reconstruction

Complete at least one of the following entries in this section by checking the appropriate box and providing
the required information related to the selection. You are not required to complete more than one entry.

F.4 We have attached either documents or statements provided by affidavit that indicate that
radiation exposures and radiation doses potentially incurred by members of the proposed class,
that relate to this petition, were not monitored, either through personal monitoring or through area
monitoring.

(Attach documents and/or affidavits to the back of the petition form.)

Describe as completely as possible, to the extent it might be unclear, how the attached
documentation and/or affidavjt(s) indicate that potential radiation exposures were not monitored.

F.2. © I/We have attached either documents or statements provided by affidavit that indicate that
radiation monitoring records for members of the proposed class have been lost, falsified, or
destroyed; or that there is no information regarding monitoring, source, source term, or process
from the site where the energy employees worked.

(Attach documents and/or affidavits to the back of the petition form.)
Describe as completely as possible, to the extent it might be unclear, how-the attached

documentation and/or affidavit(s) indicate that radiation monitoring records for members of the
proposed class have been lost, altered illegally, or destroyed.

tinued ‘on. the following page.



eee
PREM ORL

ST LGUS MO.

el

SEC Petition
Division of Compensation Analysis and Support
NIOSH

4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Iliness Compensation Program Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2016
Special Exposure Cohort Petition — Form B " Page 4 of 7

Proposed Definition of Energy Employee Class Covered by Petition — Complete Part E.

£.1 Name of DOE or AWE Facility:

SCON\We
E.2. Locations at the Facility relevant to 1 trie ae

M\\ workers in all aveas of +ne Coethty

E.3 List job titles and/or job duties of energy employees included in the class. In addition, you can
list by name any individuals other than petitioners identified on this form who you believe
shor pal if included in this class:

\ob Titles ; HM whdobes

E.4_ Employment Dates relevant to this petition:
Start | q AQ End 400 a

Start End

Start End

E.5 Is the petition based on one or more unmonitored, unrecorded, or inadequately monitored or
recorded exposure incidents?: © Yes O No

If yes, provide the date(s) of the incident(s) and a complete description (attach additional pages as
necessary):

Go to Part F.



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
illness Compensation Program Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2016
Special Exposure Cohort Petition — Form B ° Page 6 of 7

F.3. © IWe have attached a report from a health physicist or other individual with expertise in
radiation dose reconstruction documenting the limitations of existing DOE or AWE records on
radiation exposures at the facility, as relevant to the petition. The report specifies the basis for
believing these documented limitations might prevent the completion of dose reconstructions for
members of the class under 42 CFR Part 82 and related NIOSH technical implementation
guidelines.

{Attach report to the back of the petition form.)

F.4. 0 We have attached a scientific or technical report, issued by a government agency of the
Executive Branch of Government or the General Accounting Office, the Nuclear Regulatory
Commission, or the Defense Nuclear Facilities Safety Board, or published in a peer-reviewed
journal, that identifies dosimetry and related information that are unavailable (due to either a lack
of monitoring or the-destruction or loss of records) for estimating the radiation doses of energy
employees covered by the petition.

(Attach report to the back of the petition form.)

G. Complete Part
All P- the petition. A maximum of three persons may sign the petition.
if
Signe ores
Signature Date
Signature Date
Notice: Any person who knowingly makes any false statement, misrepresentation, concealment of
* fact or any other act of fraud to obtain compensation as provided under EEOICPA or who
knowingly accepts compensation to which that person is not entitled is subject to civil or
administrative remedies as well as felony criminal prosecution and may, under appropriate
criminal provisions, be punished by a fine or imprisonment or both. | affirm that the information
provided on this form is accurate and true.
Send this form to: SEC Petition
Division of Compensation Analysis and Support
NIOSH

4676 Columbia Parkway, MS-C-47
Cincinnati, OH 45226

if there‘are additional petitioners, they must complete the: Appendix Forms fo additional petitioners.
«The Appendix forms are located at'the end of this. document.

WORD ON Bpic—
. ove) ~y



Special Exposure Cohort Petition U.S. Department of Health-and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention

lliness Compensation Program Act National Institute for Occupational Safety and Health

ca: OMB Number: 0920-0639 Expires: 07/31/2016

Special Exposure Cohort Petition — Form B Page 4 of 7
po& > Use of this form is voluntary: Failure to‘use this form will not result in’ *

é “_the denial of any right, benefit, or privilege to which you may be.entitled./<

General Instructions on Completing this Form (complete instructions are available in a separate packet):
Except for signatures, please PRINT all information clearly and neatly on the form.

Please read each of Parts A-G in this form and complete the sections appropriate to you. If there is more
than one petitioner, then each petitioner should complete those sections of Parts A — C of the form that apply
to them. Additional copies of the first two pages of this form are provided at the end of the form for this
purpose. A maximum of three petitioners is allowed.

if you need more space to provide additional information, use the continuation page provided at the end of
the form and attach the completed continuation page(s) to Form B.

For Further Information: If you have questions about the use of this form, please call the following NIOSH
toll-free phone number and request to speak to someone in the Division of Compensation Analysis and
Support about an SEC petition: 1-877-222-8570.

if you
are:

Representative Information — Complete Part A if you are authorized by an Energy Employee or

Survivor(s) to petition on behalf of a class.
A.1_ Are you a contact person for an organization?

A.2_ Oraanization Information:

Name of Organization

Fosiuun ot Vonact rersut

A3 Name of Petitinn Renresentative-

Mr/Mrs/Ms. 0 rire ivannie wwauure Hiatt Lastivanis

A4 _ Address of Petitign Representative:

H Strast Ant # PO. Box
City State . Zip Code
A5 Telephone Number of Petition Representative: ( __) _

A Email Address of Petition Representative: _
A.7 (1 Check the box at left to indicate you have attached to the back of this form written authorization to
_petition by the survivor(s) or energy employee(s) indicated in Parts B or C of this form.

: a I are representing’a Survivor, go to:Part-B;.
. representing an Energy Employee, go to Part C.



nm
On this 05 day of A ovember +20 7. before me
personally appeared
to me known to be the person(s) described in and who executed the
foregoing instrument, and acknowledged that he/she executed the
same as his/her free act and deed.

IN TESTIMONY WHEREOF, I have hereunto set my hand
and affixed my official seal in the County and State aforesaid, the
day and year first above bo

My Commission Expires: 65-18

SHARON A. BELLM
Notary Public - Notary Seal
tate of Missouri
Commissioned for St. Charles Cour
My Commission Expires: August 05, 2018
Commission Number: 14997681



Special Exposure Cohort Petition U.S. Department of Heaith and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
Illness Compensation Program Act National Institute for Occupational Safety and Health

OMB Number: 0920-0639 Expires: 07/31/2016
Special Exposure Cohort Petition — Form B ° Page 2 of 7

Survivor Information — Complete Part D if you are a Survivor or representing a Survivor.

BA Name of Survivor:

Mr./Mrs./Ms. First Name Middle Initial _ Last Name

B.2 Address of Survivor:

Street Apt # P.O. Box

City State Zip Code

B.3. Telephone Number of Survivor: ( )

B.4— Email Address of Survivor:

B.5 Relationship to Energy Employee: 1 Spouse OSon/Daughter OParent
OGrandparent OGrandchild
Go.to'Part C.

Energy Employee Information — Complete Part C ESS you area

C.1 Name of Enerav Emplovee:

Mr./Mrs./Ms. . First Name Middle Initial Last Name

C.2 Former Name of Energy Employee (e.g., maiden name/legal name change/other):

Mr./Mrs./Ms. First Name Middle Initial Last Name

C.3. Address of Eneray Emplovee (if living):

Sireet : Apt# P.O. Box
City State Jin Cada
C.4 Telephone Number of Energy Employee: ( oh

C.5 Email Address of Energy Employee:

C.6 Employment Information Related to Petition:
C€.6a Energy Employee Number (if known):

C.6b Dates of Employment: Start _ | G L End 494s

C.6c Employer Name:

C.6d_ Work Site Location Kyaonne National Laboratory~ We: in
Seovile, 1D. !

C.6e Supervisor's Name:

28 = = ag, Go. to Part E. ae soe



Special Exposure Cohort Petition U.S. Department of Health and Human Services

under the Energy Employees Occupational Centers for Disease Control and Prevention
lliness Compensation Program Act Nationa! institute for Occupational Safety and Health
OMB Number: 0920-0639 Expires: 07/31/2016

Special Exposure Cohort Petiti
D. Labor Organization Information

in — Form B Page 3 of 7
Complete Part D ONLY if you are a labo:

D.1—_ Labor Organization Information:

Name of Organization

Position of Contact Person

D.2. Name of Petition Representative:

Mr./Mrs./Ms. First Name Middle Initial Last Name

D.3 Address of Petition Representative:

Street Apt # P.O. Box
City State Zip Code
D.4__ Telephone Number of Petition Representative: ( )

D.5 Email Address of Petition Representative:

D.6 - Period during which labor organization represented energy employees covered by this petition
. (please attach documentation):
Start End

D.7 Identity of other labor organizations that may represent or have represented this class
of energy employees (if known):

ee ee ee Go to Part E.